Circumcision: The Surgical AIDS Vaccine

Voters in San Francisco — the city that has probably suffered from AIDS more grievously than any other in America — may soon vote on whether to ban a safe, one-time procedure that protects against the virus that causes AIDS almost as effectively as the annual flu shot protects against the flu. Millions of dollars and years of research have thus far failed to overcome the diabolical obstacles to making an HIV vaccine. No doubt exists, however, that another treatment provides protection so effective that health experts have called it a "surgical vaccine." Unlike a flu shot, this protection lasts a lifetime and, at no extra charge, also helps reduce HIV risk for a man's sexual partners.

By now you may have guessed that this remarkable procedure is male circumcision (the word is Latin for "cutting around"), the ancient operation that removes the foreskin, the sleeve of tissue that sheathes the tip of the penis. Circumcision plays an important role in both the Muslim and Jewish religious traditions as well as in initiation rituals practiced by ethnic groups around the world, particularly in sub-Saharan Africa. Recently, however, retired hotel credit manager Lloyd Schofield, a San Francisco resident who calls himself an "intactivist" and considers circumcision mutilation, has announced that he is gathering signatures to put a referendum on the November city ballot that would ban the procedure. "Just as females are protected from having a drop of blood drawn from their genitals, baby boys deserve the same protection," Schofield told CNN. To qualify the proposition, proponents would need to gather slightly more than 7,000 signatures by late April.

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Schofield is pushing the circumcision ban even though multiple lines of very strong evidence — from epidemiology, physiology, microbiology and three large, internationally recognized "gold standard" clinical trials — converge on the conclusion that removing the foreskin drastically cuts a man's risk of becoming infected by HIV. It also reduces his risk of other sexually transmitted diseases and cancer of the penis and his female partners' risk of cervical cancer. Moreover, the operation is safe, takes less than half an hour, heals in weeks and is so common that 80 percent of American men are circumcised. Nor is there scientific evidence of untoward effects, either immediately after healing or later in life, on men's health, sexual performance or desire.

The three controlled clinical trials took place in Kenya, South Africa and Uganda, in areas where circumcision rates are low and HIV levels high. More than 11,000 men, most of them young, all of them HIV-negative, uncircumcised and willing to undergo the operation, were randomly assigned either to be circumcised immediately by a doctor, or to be in the control group and wait for circumcision until after the study ended. The three trials were all stopped early, however, because of interim results so strong — a 60 percent reduction in infection risk — that researchers could no longer ethically withhold a procedure shown to be so beneficial. After the South African clinical trial had run for 18 months, for example, 49 of the 1,446 members of the control group had contracted HIV. But just 20 of the 1,431 in the circumcision group had become infected.

Dr. James Shelton, science adviser to the Bureau of Global Health of the U.S. Agency for International Development, believes the true reduction in risk is even larger than 60 percent but was masked by the structure of the experiment. Detailed statistical analysis of the results, he writes, reveals "a protective effect of 76 percent." That analysis would raise the level of protection into flu-shot range, which begins at 70 percent, according to the Centers for Disease Control and Prevention.

The World Health Organization and UNAIDS, the United Nations' HIV/AIDS agency, describe the trial results as "compelling." The two groups now recommend circumcision as "part of a comprehensive HIV prevention package."

A number of African countries have responded with programs to provide circumcision on a wide scale, particularly to men who already are or are about to become sexually active, because they make the most immediate impact on infection rates. As knowledge of circumcision's protective effect has spread, uncircumcised men have flocked to have the operation — among other things, women are urging their husbands to go — and parents have increasingly asked to have their sons circumcised. In 2006, a near-riot erupted in Mbabane, the capital of Swaziland, when men waiting outside a clinic learned that they wouldn't all be getting the appointments they hoped for.

Circumcision's origins are unknown, but its history goes back at least 4,000 years, as shown by tomb paintings from Egypt's sixth dynasty depicting men undergoing the procedure. The Hebrews, of course, have practiced it since ancient times, and it was customary among other peoples in the Middle East and East Africa long before the birth of Islam. Circumcision's ceremonial uses generally involve establishing identity, whether as a member of a community or as an adult. Many scholars argue, however, that the practice first arose out of health concerns, especially to avoid the painful irritations and infections that can result from sand becoming lodged under the foreskins in dry, desert climates. That was the reason, for example, that Australian army doctors during both world wars performed large numbers of circumcisions on soldiers serving in North Africa and the Middle East.

Depending on the ethnic and religious composition of a particular country, the number of circumcised males in Africa ranges from less than 20 percent to more than 80 percent. The large difference in HIV rates between countries with high and low rates of circumcision became obvious more than 20 years ago, alerting scientists to the potential protective effect of the procedure.

Researchers believe that the area between the foreskin and the penis shaft provides a hospitable area for HIV to exist, post-intercourse. And physiological research has identified a likely mechanism for infection there: The foreskin contains a particular type of cell that can provide the HIV virus a direct route into the body. These cells — known as Langerhans cells and discovered by the same German doctor who also found the better-known isles or islets of Langerhans in the pancreas — are plentiful on the underside of the foreskin but absent from the rest of the penis. Like the T cells that are a major target of the HIV virus, Langerhans cells belong to the immune system and are highly susceptible to HIV infection.

The shaft of the penis lacks Langerhans cells but contains a protective material called keratin that helps block entry of the virus. After circumcision, keratin develops in the tip of the penis, rendering it less vulnerable. The HIV protection that circumcision provides is not perfect, and public health authorities emphasize that circumcised men must still practice safe sex to limit risk.

Still, the clinical trials demonstrated the strong protective effect of circumcision in vaginal intercourse, which is important in Africa because the epidemic there has spread largely by heterosexual activity and involves people of both sexes. The logic of the physiology, however, argues that circumcision should also protect men who take the insertive role in sex with other men, although this proposition has not been tested. It is clear, however, that by reducing the number of men who become infected, circumcision also reduces their partners' exposure to the virus.

"Herd immunity" is the name epidemiologists give to the reduction in risk that people not themselves vaccinated enjoy when a vaccine cuts the amount of an infectious agent that is circulating in a population. With HIV, this type of protection extends not only to circumcised men's female partners but, by cutting women's risk, to their babies as well. Fewer men becoming infected with HIV means fewer people of both genders and all ages getting the infection.

In rich countries in recent years, HIV treatment has improved so drastically that being infected no longer constitutes an imminent death warrant. Modern drug therapies now keep HIV-positive people alive for years, but in the United States each year, nearly 60,000 new people still join the more than 1.2 million already living with HIV. And 1 in 5 people with the infection don't know they have it, which helps it continue to spread. People are still dying, and treatment is costly and complicated.

Any injection offering a 60 percent reduction in the risk of contracting this plague would be received as a miracle in the HIV-ravaged regions of the world — and probably as a Nobel Prize-worthy triumph in the scientific community. Despite all these advantages, of course, some people do not think circumcision appropriate for themselves or their sons. That is certainly their right. But why would anyone — in San Francisco, which has known firsthand the grievous cost of HIV, or anywhere else — want to deprive those who wish this protection of the ability to obtain it?